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Health Security Issues: Can Our Public Health Programs

Handle It?

04 November 2018

Meiwita P. Budiharsana
1. Introduction
In today’s global environment, Indonesia must confront similar public health challenges
in protecting its population healthy and preventing the cross-border spread of emerging
and re-emerging infectious (viral) diseases (EIDs) such as SARS, Avian influenza, MERS,
Zika, and others that have a dramatic impact within a relatively short period of time. The
first EID case may occur in any area of Indonesia, but if we have no capacity to detect,
prevent and respond to it, this can become the beginning of a global pandemic. As life
expectancy increases worldwide, issues related to noncommunicable conditions are
becoming the center of attention. Nonetheless, we have to keep watching EIDs, especially
zoonotic diseases that originally threaten animals only.
After the 2003 outbreak of severe acute respiratory syndrome (SARS), preparedness for
such public health emergencies was becoming a priority to all countries. The appearance
and rapid international spread of SARS demonstrated to all how an infectious disease
can rapidly cross borders and deliver health threats and economic blows on an
unimaginable scale. In addition, the rapid spread of the highly pathogenic avian
influenza virus (H5N1) in some Asian countries, including Indonesia, which then
spanned across Europe and into Africa, has put the world on high alert for an influenza
pandemic and affirmed the urgency of strengthening public health systems and capacity
worldwide. The WHO announced the member countries commitment to implement the
International Health Regulation (IHR) 2005 so that countries can benefit through
improved national and international surveillance; improved systems for rapid detection
of and response to public health emergencies; standardized rules for evaluation, control,
and resolution of urgent events; and mechanisms to increase national and local public
health security. Nonetheless, the success of IHR (2005) and other global public health
initiatives such as the Sustainable Development Goals depend on how strong the national
public health systems are.
This paper is questioning the MoH's essential public health functions (EPHFs)
preparedness, as we are currently lag behind in public health capacity and infrastructure,
and our Essential Public Health Functions (EPHFs) have been deteriorated since the
beginning of decentralization and got even worse after the National Health Security
(Jaminan Kesehatan Nasional) was launched in 2014. Do you think that an overall public
health program evaluation is actually necessary? At least to assess whether Indonesia has
sufficient human resources, funding resources, and health facilities to control existing
endemic infectious diseases such as HIV/AIDS, acute lower respiratory tract infections,
diarrheal diseases, measles, tuberculosis, malaria, and the neglected tropical diseases.
What will happen if another public health emergency of international concern (PHEIC)
hits us? What should be prioritized in strengthening the practice of public health in
Indonesia? Don't you think that we should also ask the MoH whether we can achieve the
SDG targets by 2030?

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2. Essential Public Health Functions (EPHF) - Current Situation
According to WHO and PAHO, Essential Public Health Functions are obligatory
government responsibilities to improve, promote, protect, and restore people’s health
through collective action. The ten essential public health services are shown in Figure 1
(1),(2),(3),(4):
1. Monitor health status to identify and solve community health problems;
2. Diagnose and investigate health problems and health hazards in the community;
3. Inform, educate, and empower people about health issues;
4. Mobilize community partnerships and action to identify and solve health
problems;
5. Develop policies and plans that support individual and community health efforts;
6. Enforce laws and regulations that protect health and ensure safety;
7. Link people to needed personal health services;
8. Assure competent public and personal health care workforce;
9. Evaluate effectiveness, accessibility, and quality of personal and public health
services;
10. Research for new insights and innovative solutions to health problems.

Figure 1 Ten Essential Public Health Functions (EPHF)


Source: PAHO. The Essential Public Health Functions as a strategy for improving overall health systems
performance: Trends and challenges since the Public Health in the Americas Initiative, 2000-2007.
Washington, DC: PAHO; 2008.

Indonesia is the second most populous country in Asia and the fourth largest in the
world. The population (about 260 million in 2018) is characterized by its wide diversity -
demographic, economic, social, political, and cultural. The country is divided into 34
provinces, each of which has a legislative council headed by a governor. These provinces

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include 514 districts (kabupaten/kota), nearly 7,000 subdistricts (kecamatan), in which there
are approximately 80,000 villages. Increasing urbanization has decreased the proportion
of people living in rural areas down to 56 percent(5). In 2014, the MoH’s regulation
Permenkes No. 75/2014 redefines the scope of work of essential public health functions
(EPHFs) to continue covering both community health efforts or Upaya Kesehatan
Masyarakat (UKM) and a limited basic individual health services or Upaya Kesehatan
Perorangan (UKP), with the puskesmas (community health center) at a sub-district
(kecamatan) level as the responsible health institution in charge.

The EPHFs include the following UKM activities (see Lampiran Permenkes-75 section VIII,
pp. 92-100):
a. Health promotion, to include:
 community education - school health services, community education on mental
health, antenatal care & breastfeeding, risk-populations (aging, children,
adolescence with drug abuse), personal hygiene, dental care, immunization,
adolescent reproductive health counseling, HIV-AIDs and STIs, diarrhea, typhoid,
hepatitis, education on complementary infant and child feeding, complementary
feeding of breastfed child, malnutrition, severe malnutrition, dietary and
complementary feeding for severe malnourish pregnant women, dietary
counseling, education and counseling about self-medication and drug use;
 community empowerment through religious and public figures, cadres, local PHBS
or ‘healthy and clean behavior’ network, Posyandu, rational use of drugs and active
learning methods or CBIA);
 training of PHBS cadres, communication techniques, active learning methods
(CBIA) on drug use and self-treatment;
 advocacy about PHBS practices and problem solving, and nutrition support group;
b. Environmental Health, to include:
Monitoring public places, food management and clean water;
c. MCH and FP, to include:
Immunization, elementary school children health screening, family planning
education for reproductive age women;
d. Nutrition Service, to include:
 early detection of cases in the community, surveillance;
 nursing care to cases in the community;
e. Preventive services and control of diseases, to include:
 prevention and control of non-communicable disease (posbindu-PTM);
 prevention and control of communicable diseases (filariasis, worms, dengue (DBD),
malaria, HIV/AIDS, sexual transmitted infections (STIs), zoonosis and vaccine
preventable diseases)(6),(7).

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In addition, the individual health services or Upaya Kesehatan Perseorangan (UKP) is
defined as services to maintain and improve individual’s health, and prevent the
emergence of individual’s health problems. A puskesmas usually provide UKP or curative
care five days a week, within limited hours(6),(7).

The Permenkes No. 75/2014 includes also the provision of non-essential public health
services called Development Public Health Functions (DPHFs), pending on resources,
geographical and health priority considerations (see Lampiran Permenkes-75 section VIII,
pp. 100-102). This DPHFs include specific services in relation to narcotics/harmful drugs,
dental care for children, aging and pregnant women, traditional medicines, occupational
health, and others. This Permenkes also establishes rules on where a puskesmas with in-
patient care (puskesmas rawat inap) can be built, considering the local population
distribution, available resources and attainable distances from out-patient puskesmas
(puskesmas non-rawat inap) and/or primary care facilities in the same sub-district. An in-
patient puskesmas has a maximum of five beds and is allowed to provide a maximum of
five-day in-patient care. Then, they shall refer the patient to a hospital if a longer period
of care is needed. For disadvantaged areas, borders and outermost islands (Daerah
Tertinggal, Perbatasan dan Kepulauan Terluar) an in-patient puskesmas can have a maximum
of ten beds or more pending on the availability of resources(6),(7). Furthermore, DPHFs
are divided into two areas of:
(1) development UKM components: a) mental health services, b) community dental
health services; c) complementary traditional health services, d) sports health
services, e) sensory (indra) health services, f) elderly health services, g) occupational
health services, and h) other health services;
(2) development UKP components: a) general medical examination, b) dental and oral
health services, c) MCH-FP personal services, d) emergency services, e) individual
nutrition services, f) health services delivery, g) in-patient services for in-patient
Puskesmas, h) pharmaceutical services, and i) laboratory services(6),(7).

Other functions of EPHFs such as: a) emergency and humanitarian action; b) health
research; c) health information systems; d) strategic management of health systems; e)
regulation and enforcement to protect public health; f) human health resources
development (including education and training); g) promotion of equitable access; h)
quality improvement for health services – are the responsibility of the central MoH level.
Looking back at the history, the 1998 EPHFs were simply described as: (1) immunization,
(2) monitoring morbidity and mortality, (3) diseases outbreak control, (4) disease
surveillance, (5) promotion of community involvement in health, (6) monitoring
determinants of health, (7) production and protection of safe water, (8) control of food
quality and safety, (9) provide health information and education, and (10) evaluate

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effectiveness of health programs and services (8). Today, disease surveillance is not
mentioned at all in the Permenkes No.75/2014.

Recently, there has been growing recognition of the benefits of skilled medical care from
the demand side. The 2014 JKN has finally relaxed access and cost as the main barriers
of health care utilization. Inattentive and incompetence medical personnel combined
with substandard quality of health care delivery are current contributors to premature
and preventable deaths, in particular maternal deaths. Administratively, the Ministry of
Health (MoH) is merely managing and collecting data from government owned hospitals
and community health centers (puskesmas), instead of its responsibility to supervise and
evaluate the quantity and quality of both public and private health services. The current
misperception of the purpose of JKN capitation payment to the puskesmas (since 2014) has
turned puskesmas into a more clinical (curative) services center, and no longer as a center
for primary health care (PHC).

Formerly (pre-JKN), the Indonesian National Health Development Program was


founded on a primary health care (PHC) concept with the puskesmas as the basic health
care facility, supported by hospitals and other community-based health care facilities. In
each subdistrict, there is at least one puskesmas headed by a doctor, and supported by two
or three subcenters (pustu) of which the majority are headed by nurses. Health centers
focus on health promotion, sanitation, mother and child health (MCH) and family
planning (FP), community nutrition, disease prevention, and minor emergencies. At the
village level, the integrated health post (posyandu) serves as the first line of care,
followed by basic professional care at puskesmas. Thus, community-based health care
delivered by a puskesmas has been a cornerstone of the public health system in Indonesia
since its inception in 1968.

A puskesmas must conduct several health promotion and prevention outreach activities
in collaboration with community health volunteers (kaders) each year. Early initiatives in
maternal and newborn care focused on the provision of care through puskesmas and pustu
(community health sub-center). In 1989, the village midwife program (Bidan di Desa) was
introduced whereby a trained midwife was placed in each village along with a village
birth facility (polindes). This program also became an integrated part of the monthly
community health extension post (posyandu), offering antenatal care (ANC) and
reproductive health consultations at the village level. Gradually, these community-based
efforts have overcome the traditional harmful practices introduced by local traditional
birth attendants. The lowest level of primary care, or posyandu, is in the villages,
organized by kaders or volunteers selected by the head of the village or a village
committee. One volunteer usually covers 10 households. The volunteers encourage
women with high-risk pregnancies to seek prenatal care in due time, and help these

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women to arrange transportation to a health facility. They are typically literate and have
completed primary school, and supervised by staff from the puskesmas, who are in turn
guided by a working group composed of representatives of the Ministry of Home Affairs,
Ministry of Health, National Development and Planning Bureau, local government,
Family Planning Coordination Board, and Women's Empowerment Movement (PKK).

In short, the organization of health service delivery in Indonesia is through five levels:
village, subdistrict, district, province, and central. A Puskesmas or a community health
center is supposed to focus on the UKM part of EPHFs, or the health promotion and
prevention programs such as mother and child health and family planning, community
nutrition, sanitation, and disease prevention; and, which in reality only spend a limited
time (about three hours between 9.00am – 12.00 noon) on curative care or minor
emergencies services. In practice, we see some complications, such as:
a) some puskesmas in rural areas have not succeeded in carrying out both curative and
preventive tasks because the responsible doctor(s) who work(s) in those puskesmas
do not live in the same rural areas;
b) a large number of nurses posted to rural areas also open private practices in nearby
villages or cities;
c) only around 70 percent of midwives remain to live in villages; the others migrate to
cities;
d) cadres or voluntary community members that a puskesmas collaborates with, may ask
for fees or transportation costs when asked for disseminating specific health
promotion messages at the village level, or, in some places where the posyandus cannot
recruit enough volunteers to serve the community, the posyandu does not provide
adequate information or activities;
e) it was already concluded that cadres are generally ineffective in fulfilling their roles
in the community because they are not professionals and usually show little
accountability;
f) if Indonesia invests more seriously in human resources at all levels, these well-
trained community health promoters will be able to demonstrate a substantial
impact on maternal and newborn health(9);
g) public health facilities such as public hospitals and health centers (puskesmas) became
the sources of revenue (PAD) for local governments (PEMDA). These facilities receive
subsidies from the central government for salaries and operational costs, but the
puskesmas is required to adopt the self-supporting (swadana) principle, which means
they must use the user fees to finance the non-salary costs of medical services.
This swadana principle makes local governments keep raising revenues by contracting
out services to the private sector. The system has led to growth in the number of private
sector health institutions, and two-thirds of the financing and more than half of the
services are now in the private hands(10);

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h) post-decentralization (2001), the central government did not provide health staff for
local communities anymore. Some local governments did not consider “bidan di desa”
a priority anymore. Many village midwives left their polindes for sub-urban or urban
areas, where opportunities in private practice are far greater(10).

In conclusion, the Indonesian health system gave a relatively high priority to EPHFs two
decades ago. Since 2014, these priorities have been downgraded. A much higher priority
is given to individual health services or Upaya Kesehatan Perseorangan (UKP) since JKN
started in 2014. This was further encouraged by the current 2015-2019 MOH Renstra
under the instruction to prioritize the JKN, the Indonesia Healthy Card and the National
Social Protection System (Sistem Jaminan Sosial Nasional, SJSN-Kesehatan). In its
introduction (Chapter I), the MoH Renstra declared that strengthening preventive
promotion and community empowerment was one of the three main strategies. But, in
Chapter III, the emphasis of the activities are directed to strengthen curative care in
support to the expansion of the JKN(11). The result is that public health activities that
cover public goods, including surveillance, preparedness and responses towards
preventing disease outbreaks are no longer priorities.

Further, the Renstra (2015-2019) has already downgraded the priority previously given
to family planning and nutrition. Both are vital services for a strong public health effort.
Effort to improve women’s health and nutrition far before they get pregnant, in particular
during adolescence was merely mentioned as ‘important factors’ to reduce maternal
deaths and infant deaths without any specific program measures and targets were stated.
Since the MOH Renstra 2015-2019 is a guideline for all planning and implementation of
health development by all stakeholders at central and local levels, and by supported
sectors and the private sector, the lack of inclusion of family planning and nutrition
targets in the Renstra means that no attention would be paid during the translations into
Programs Action Plan or RAP (Rencana Aksi Program) by Echelon I and Activities Action
Plan or RAK (Rencana Aksi Kegiatan) by Echelon II levels.

The launching of the National Health Insurance (JKN) in 2014 has damaged the EPHFs
performance in Indonesia. The MoH Regulation No.19/2014 - Chapter I, Article 1 clause
(2) sent mixed-messages about the function of primary health care facilities(12), “primary
health care facilities (Fasilitas Kesehatan Tingkat Pertama or FKTP) is a health facility delivering
non-specialist individual health care for the purposes of observation, diagnosis, care, treatment,
and/or other types of health services”; and Article 1 clause (3) supplemented it with,
“capitation fund is the amount of prepaid monthly payment to FKTP based on the number of
registered participants regardless of the type and amount of health services provided ...”.

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The MoH Regulation No.19/2014 Chapter I Article 2 emphasizes a more flexible use of
JKN capitation funds by FKTP owned by regional/local government. While previously a
puskesmas as a technical implementation unit (UPT) of the District Health Office must
process all budgeting issues through the District Health Office, now after the 2014 JKN a
puskesmas can keep, manage, and spend their capitation funds by themselves as long as
they create a Regional Public Service Agency (Badan Layanan Umum Daerah or BLUD).
This BLUD autonomy has been affirmed also by the Law No.23/2014 Article 346. As a
result, the JKN capitation funds is treated as an additional reward to puskesmas staff who
delivered curative services according to their position/ranks.

The MoH Regulation or Permenkes No.19/2014 Chapter II Article 3 clauses (1) and (2)
explicitly describe that capitation funds can be utilized by FKTP to: a) 60% for income on
top of salary among health workers and non-health workers who perform services on the
FKTP; and, b) 40% for operational costs of health services (not limited to the FKTP but
also for a range of related services that may include the District Health Office). The
original intention was to provide flexible funds at puskesmas to procure needed logistics,
to cover maintenance costs, to hire non-civil service professionals, and to conduct other
innovative activities. However, this is no longer the primary purpose of the funds which
can now be used for a range of unspecified purposes. While all these changes increase
discretion in the use of these funds by local health authorities to address local health
priorities, the mechanisms for setting these priorities and ensuring that funds are
allocated to them, are lacking. Puskesmas is now under the local government, under the
Ministry of Home Affairs (MOHA). Regulation No 61/2007 states that the Local
Government Head (Bupati or Walikota) is responsible for the use of this BLUD budget.
Ultimately, these funds are under the control of the Bupati/Walikota.

In general, puskesmas staff turned their attention away from preventive and promotive
outreach activities and concentrate on curative services (the UKP component of EPHFs),
shifting their allegiance to BPJS-K. Within a relatively short time, almost all puskesmas
created BLUD unless the District Health Office has created it first. The BLUD funds were
used for various things. Some puskesmas created new maternity wards even though they
do not have trained midwives for basic and emergency obstetric and newborn care
(BEmONC). The clause in Permenkes No.19/2014 - Chapter I Article 1 paragraph (3)
allows BPJS-K to continue provide capitation fund based on the number of registered
JKN participants without monitoring the utilization of the funds and the amount of
services provided. The damage has been done, the puskesmas staff’s motivation to
implement the UKM components of EPHFs have decreased; quantity and quality of
health promotion and prevention have deteriorated.

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In 2018, the MOHA (KemenDagri) issued a Government Regulation or Peraturan
Pemerintah (PP) No. 2/2018 on Minimum Health Service Standard (SPM-K) which
required FKTP at the primary care level to consider the type and amount of health
services provided when services are funded by Local Government Budget or Anggaran
Pendapatan Belanja Daerah (APBD). However, the SPM-K does not contain details of the
services to be provided or targets to be met. This technical details should be done by the
MoH through Permenkes, including the details and targets. The SPM-K under the
regulation (PP) No.2/2018 balances the fulfillment of citizens’ basic health needs (the
rights to access health services) with the minimum standard of services that the
government can afford. In addition, the Government Regulation No.38/2007 establishes
the Norms, Standards, Procedures and Criteria (NSPK) for these services. Basic services
in SPM-K is an obligation for the regional/local government at both provincial and
district levels(13). However, health services for victims of natural disasters and
extraordinary events, including global public health emergencies, are the responsibility
of the provincial government(14).

It is unclear whether the MoH has the capacity to improve the eight core-requirements to
implement IHR in the next RPJMN period (see Annex 6 Figure 8 on the Organizational
Structure of Ministry of Health under Permenkes No 64/2015)(15). The flagship is usually
held by the institution that is more advanced in using the technology to be applied. In
the case of public health emergencies due to epidemic of zoonotic diseases (EIDs), the
technology to control pathogens that spread between animals and people is within the
Ministry of Agriculture (MoA) Directorate General of Livestock and Animal’s Health.
Moreover, to contest violation against food safety regulation and Anti-Microbial
Resistance, the flagship is in the National Drug and Food Control Agency or Badan
Pengawas Obat dan Makanan (BPOM) which reports directly to the President (under
Presidential Decree No.103/2001). Badan POM is the one who has the knowledge to
control both the prescribed and over-the-counter pharmaceutical drugs (medications),
vaccines, biopharmaceuticals, dietary supplements, food safety and cosmetics(16).

The HSR concludes that the current state of EPHFs are declining. The MoH has very
limited capacity for inter-sector coordination and collaboration, both of which are vital to
an effective disease surveillance and public health emergency response. Health
promotion and prevention are both weak and have seldom yielded any satisfying outputs
and outcomes. As a result, we see an increase of (often undetected) tuberculosis, HIV,
AMR and drug-resistance, anemia, diabetes, hypertension, road accidents and impact of
climate change(17),(18). In the near future, as required by IHR, Indonesia should not
continue practicing a fragmented national approach to disease control. This means an
integrated plan to harmonize the animal health measures and human systems of disease
surveillance, diagnosis and control is in place. In the era of EIDs, and from the economic

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costs that animal disease outbreaks can trigger, we should consider animal’s health as
important as human’s health. The question is whether health security issues (detection
of infections caused by antimicrobial resistance pathogens, response to infectious and
potential zoonotic diseases, real-time surveillance and data analysis, and preparedness,
i.e., mapping of priority public health risks and resources) can be added into the
workload of current EPHFs? Establishing clear lines of authority on who should handle
public health emergencies based on EIDs is vital.

3. Health Security - Current Situation


Within less than 48 hours, an Emerging Infectious Disease (EID) can spread from a village
in Indonesia to any major city in Southeast Asia and then to the whole world. Ensuring
that Indonesia is safe from global pandemics means confirming to the world that
Indonesia has acquired the core-capability to implement the IHR (2005). When the
International Health Regulations (2005) were issued on 15 June 2007, each member
country was given a nine-year period (2007 – 2016) to gradually meet the required eight
core capacities to prevent, detect, and respond to biological and other potential hazards.
The IHR 8 core capacities are: (1) Legislation and Policy, (2) Coordination, (3)
Surveillance, (4) Response, (5) Preparedness, (6) Risk Communications, (7) Human
Resources, and (8) Laboratory. These capacities need to be in place, to assure that
Indonesia is prepared to detect, prevent and respond to: (1) emerging infectious diseases
(EIDs) and zoonotic diseases, (2) radiological-related diseases, (3) chemical-related
diseases, and (4) food-related diseases (19). In less than nine years, Indonesia declared its
ability to implement IHR fully, but the 2017 JEE results showed that some core activities
received low scores as low as 2(20).

Why does Indonesia need to declare its ability to implement IHR fully? Globalization
means that a public health emergency or event in one country can be a threat to others.
In the last couple of decades, Emerging Infectious Diseases (EIDs) or known as Penyakit
Infeksi Emerging (PIE) show an increasing trend in the world and in Indonesia. Although
the introduction of mass immunization programs, the discovery of antibiotics, and the
eradication of smallpox in 1979 led to the impression that we had won the battle to control
infectious diseases(21), the portrait changed as we entered the 1980s. The HIV/AIDS
pandemic - an animal origin zoonotic disease - caused so many deaths; and more
frequently outbreaks of emerging pathogens were reported. Basic public health activities
like vaccination became more difficult to implement. At the same time, the rapid growth
of global trade and travel (3.6 billion international air passengers in 2016) have facilitated
the spread of emerging microbial pathogens to all parts of the world including Indonesia.
The imminent threat of antimicrobial drug resistance has reduced our confidence about
being able to successfully treat many life-threatening infections. The outbreak of severe
acute respiratory syndrome (SARS) in 2003 was a wake-up call to the global public health

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community that there was no international vehicle for rapidly detecting and responding
to a multi-country outbreak, particularly if caused by a respiratory-transmitted agent(21).

The 2006 avian influenza outbreaks and the 2009 pandemic of influenza A (H 1N1) was a
serious notice that Indonesia was still ill-prepared for global public health emergencies.
Subsequent emerging microbial threats, including severe acute respiratory syndrome
coronavirus (SARS-CoV) that was first reported in Asia in February 2003 had spread to
more than two dozen countries in North America, South America, and Europe. Other
outbreaks were: cholera in Haiti (2010), Middle East respiratory syndrome coronavirus
(MERS-CoV) in the Middle East and Korea (2012), Chikungunya in 2013 and Zika in 2015
in the Americas, yellow fever in Africa in 2015–2016 and in South America in 2016–2017,
and cholera in Yemen (2017). The Ebola epidemic in West Africa in 2014–2016 was a
glaring example of global prevention and response insufficiencies(22)(23).

In Indonesia, antimicrobial resistance (AMR) and zoonotic diseases are increasing in


incidence, threatening food safety, biosafety and biosecurity. All of these are signs that
EIDs pose international security threats, and place potential negative impacts on our
public health infrastructures, people’s health, social and economic circumstances, and
welfare (21,22,24). The RPJMN must include explanations of why emerging and re-
emerging infectious diseases are increasing in both pace and spread; why serious and
unusual disease events are increasing and inevitable; and why the threat of deliberate use
of biological and chemical agents, laboratory and industrial accidents is growing.

Emerging Infectious Diseases (EIDs) are infectious diseases that can be classified by
causative agent (bacterial, viral, parasitic or fungal). An EID is defined as an infectious
disease whose incidence has increased in the past 20 years and will continue to increase
in the near future. Most of the Emerging Infectious Diseases (EIDs) are zoonotic(25). The
MoH admitted that Indonesia is facing a triple burden of diseases condition: (a) the rise
of non-communicable diseases as leading causes of mortality and morbidity since 2010
(i.e., stroke, heart diseases, diabetes mellitus)(26–28); (b) the re-emergence of
communicable diseases (i.e., tuberculosis, diarrhea (E. Coli), dengue fever) including
existing but neglected tropical diseases (i.e., yaws, schistosomiasis); and (c) the new
emerging communicable diseases (i.e., avian influenza, SARS and swine influenza)(29).
The newly emerging diseases are recognized in the human host for the first time, while
reemerging infectious diseases have historically infected humans then continue to appear
in new locations or in drug-resistant forms or reappear after apparent control or
elimination. The description of “reemerging” new or more severe diseases are associated
with acquisition of new antimicrobial resistance (AMR) genes. Drug resistance mutations
have caused the re-emergences of certain pathogens such as multidrug-resistant and

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extensively drug-resistant (MDR and XDR) tuberculosis, drug-resistant malaria, and
numerous bacterial diseases such as vancomycin-resistant enterococci(30).

In the past, EIDs have caused some of the deadliest pandemics such as the Black Death
pandemic (25–40 million deaths) in the 14th century, the 1918 influenza pandemic (50
million deaths), and the HIV/AIDS pandemic (35 million deaths so far). About 60 to 80
percent of new human infections originate in animals, especially rodents and bats, which
are then manifested as Hantavirus pulmonary syndrome, Lassa fever, and Nipah virus
encephalitis(30). The Severe Acute Respiratory Syndrome (SARS), which emerged from
bats can spread into humans, then by person-to-person transmission in confined spaces,
hospitals, and finally by human movement between international air hubs. The 2009
H1N1 pandemic influenza virus emerged from pigs. H5N1 influenza (avian influenza)
emerged from wild birds to cause epizootics that amplified virus transmission in
domestic poultry, and then to poultry-exposed humans. Both the highly pathogenic avian
influenza (HPAI) and low pathogenicity avian influenza (LPAI) can cause severe illness
in humans, with H5, H7 and H9 viruses as the main pathogens(30),(31).

Other important reemerging infectious disease agents which first appeared long ago but
have survived and persisted by adapting to changing human populations and
environments are Dengue virus and West Nile virus. The association of dengue
with Aedes mosquitoes that live in and around human habitations means that crowding,
poor sanitation, and poverty provide ideal environments for transmission to humans(30).
Other examples of re-emerging infectious diseases are: (1) cholera, which has repeatedly
reemerged over more than two centuries associated with global travel, war, natural
disasters, and inadequate sanitation, poverty and social disruption; (2) HA-MRSA or
hospital acquired infection (also prisons and nursing homes, people with open wounds,
catheters, and weakened immune systems), community-acquired (CA-MRSA) as well as
livestock acquired (LA-MRSA) infections; and (3) Clostridium difficile infection (CDI), the
major cause of infectious diarrhea in hospitalized patients. MRSA and CDI eventually
become resistant to treatment(30).

It seems unlikely that we can eliminate most EIDs in the future. Pathogenic
microorganisms can undergo rapid genetic changes, leading to new phenotypic
properties that take advantage of changing host and environmental opportunities. The
1918 influenza pandemic virus is one example. Over the past 95 years, its descendants
have evolved continually and then producing new pandemics in 1957 and 1968, and
recently in the 2009 pandemic H1N1 influenza. In addition, microbial advantages can be
met and overcome only by aggressive vigilance, ongoing dedicated research, and rapid
development and deployment of surveillance tools, diagnostics, drugs, and vaccines – in
the animal sector as well as the human sector. Each new disease brings unique

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challenges, forcing us to continually adapt to ever-shifting threats(30). About six out of
every 10 known infectious diseases in people originate in animals, and three out of every
four EIDs are spread from animals(32).

One Health is an approach promoted by the Tripartite organizations, FAO, OIE and
WHO as well as many countries and organizations to caution all nations that no single
nation or sector can ensure global health security. Indonesia must work across internally
and with other countries to prevent, detect, and respond to infectious disease threats in
order to protect people and livelihoods, and to contribute to the creation of a safer
world(33). Public health security includes all activities (both proactive and reactive) that
can minimize vulnerability to acute public health events that endanger people, their
animals and livelihoods living across geographical regions and international boundaries.
Also, chemical, biological, and radio-nuclear events that have the potential to create
‘Public Health Emergencies of International Concern’(33). Pandemic disease threats and
ineffective responses can also have a devastating impact on public health, the country
and global economy(34).

Any large-scale incident (infectious disease pandemics or natural disasters), whether it is


naturally occurring, or an intentional and/or accidental outbreaks, which will endanger
the security and stability of a society, will then activate actions related to 2005 IHR Article
21 (1) and (2) on Ground crossings:
“Where justified for public health reasons, a State Party’s ground crossings might be
designated …” and therefore, “States Parties sharing common borders should consider to
enter into bilateral or multilateral agreements or arrangements concerning prevention or
control of international transmission of disease at ground crossings …”.

The launch of GoI’s compulsory JKN in 2014, was a great commitment to “urgently and
significantly scale up efforts to accelerate the transition towards universal access to affordable and
quality healthcare services”(35). The ultimate goal of JKN is to avoid amenable,
preventable, and early deaths. But, JKN cannot prevent deaths due to an unprecedented
outbreak of EIDs. When Ebola virus hit the African continent, with 11,000 deaths
occurred in just three months in three countries (Guinea, Liberia and Sierra Leonne), we
see an enormous human and economic costs that a pandemic threat could create in the
absence of strong preparedness and response systems to tackle health emergencies.
A high-level forum on UHC in 2017 had declared that UHC needs to include pandemic
preparedness, in recognition of the inseparable nature of the SDGs, especially target 3.d
of the SDGs which seeks “to strengthen the capacity of all countries, in particular
developing countries, for early warning, risk reduction and management of national and
global health risks”(35).

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3.1 Antimicrobial Resistance (AMR) and Antimicrobial Usage (AMU)
The interconnected issues of Antimicrobial Resistance and Antimicrobial Usage have
become one of the most substantial health issues of our time, prompting the World Health
Assembly (WHA) to urge Member States to complete national action plans by May 2017,
aligning them with the objectives of the Global Action Plan (GAP). A national action plan
covers awareness, surveillance and research, hygiene infection prevention and control,
optimal use of antimicrobial medicines, and sustainable investment (showing
measurable social and environmental impacts)(36).

AMR is the ability of a microorganism (like bacteria, viruses, and some parasites) to
inhibit an antimicrobial (such as antibiotics, antivirals and antimalarials) from working
against it. As a result, standard treatments become ineffective, infections persist and may
spread to others (37). The threat posed by “superbugs” to public health, safety, and the
global economy is staggering. Indonesia shows a high burden of AMR (see Table 1).

In terms of AMU, it cannot be ignored that two-thirds of the estimated future growth of
usage of antimicrobials is estimated to be within the animal production sector, with use
in pig and poultry production predicted to double. In recent decades, the intensification
of animal production due to the increasing demand for products of animal origin has led
to an increasing overall use of antimicrobials. While the prudent use of antibiotics is
important to treat animal diseases, its overuse and misuse can contribute to antimicrobial
resistance. Animals’ resistance to antimicrobial drugs, makes treatments ineffective,
increased severity of disease, reduces productivity and leads to economic losses. In
addition, unwanted antimicrobials residues may be present in products of animal origins,
in animal waste contaminating soil and water and the environment in general, as between
75 to 90 percent of antimicrobials used in livestock are excreted, mostly unmetabolized.
This further contributes to the emergence and spread of AMR through selection pressure
upon pathogens. In food producing animals, AMR poses a serious threat to the safety
and quality of feed and food, food security and livelihoods. Unhealthy and unproductive
animals cannot generate food products of acceptable safety and quality for human
consumption, which means cannot contribute to income generation. The insufficient
standards for residues in animal food products, would reduce the livestock sectors
potential of access to trade. Addressing AMR requires the human health and livestock
sectors to join together with others in implementing practices to minimize the use of
antimicrobials(38). The Association of Southeast Asian Nations (ASEAN) has recognized
that AMR is a significant health problem and the members have agreed to work together
(2017)(39).

In support of this agreement, Indonesia has issued the following regulations: the
PerMenKes No 8/2015 (MoH Regulation No. 8/2015) on the antimicrobial resistance

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control program in hospitals; Law No. 41/2014 as an Amendment to Law No. 18/2009
on Livestock and Animal Health; and the Minister of Agriculture’s Regulation No.14
PK.350/2017 on the Classification of Veterinary Drugs. Yet, there is insufficient
coordination and collaboration between the human health and animal health Ministries
in the current GoI National Action Plan (NAP) related to AMR and AMU. To improve
collaboration between the MoH and the MoA DGLAHS, it is recommended that an
Antimicrobial Resistance Control Committee (ARCC) be established in the Ministry of
Agriculture to foster closer coordination and collaboration with the already established
ARCC of the MoH. Ideally, both ARCCs would merge into a multi-ministerial ARCC,
including the Ministry of Marine Affairs and Fisheries (MOMAF) and the Ministry of
Environment and Forestry (MOEF). Data related to AMR and AMU in Indonesia are
extremely limited and in need of improvement through further one health investigation
and surveillance. To-date, only a handful of studies have been conducted by a few
laboratories or universities and there is no nationally networked AMR/AMU laboratory
or surveillance system set up to provide nationally representative data (40).

Table 1 Antimicrobial resistance (AMR) rate against Streptococcus pneumoniae


Antibiotic Resistance rate (%) in children/ and adults
Cotrimoxazole 1 45.0
Penicilin non-susceptible1 24.0
Chloramphenicol 2 6.0
Tetracycline1 5.0
Sulfamethoxazole 2 3.5
Erythromycin1 1.0
1 Farida et al. Population-based survey in Semarang, Indonesia 2010. Samples from Nasopharyngeal
swabs included 243 healthy children aged 6–60 months and 253 healthy adults aged 45–70 years.
Findings showed that the prevalence of S pneumoniae carriage was 27% (95% CI: 20–32), among
children was 43% (95% CI: 32–50) and among adults was 11% (95% CI: 5–15) (28).
2 Soewignjo et al. Population-based survey in Lombok, Indonesia 1997. Samples from Nasopharyngeal
swabs of 484 healthy children (aged 0-25 months) presented that the prevalence of S pneumoniae
carriage was 48% (41).

Table 1 presents the facts that since 2010:


a. Cotrimoxazole was no longer an effective antibiotic because 45% of the Streptococcus
pneumoniae strains were already resistant to Cotrimoxazole (a combination of
sulfamethoxazole and trimethoprim). A child patient with pneumonia (infection of the
lungs), ear infections, sinus infections, meningitis (infection around the brain and
spinal cord), and bacteremia (blood stream infection, or sepsis) caused by Streptococcus
pneumoniae is at significant risk of not getting better when being treated with
Cotrimoxazol.
b. Similarly, infections such as acute otitis media, sepsis, or bacterial meningitis will not
get better if treated with penicillin non-susceptible (PNS). The emergence of Penicillin

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Non-Susceptible Streptococcus Pneumoniae (PNSSP) has brought a new clinical
challenge(42).
c. The resistance rates of 6% against chloramphenicol, 5% against tetracycline, 3.5%
against sulfamethoxazole and 1% against Erythromycin need to be followed up in
2019-2020, to assess whether resistance rates have increased much higher.

Table 2 Antimicrobial resistance (AMR) rate against Escherichia Coli


Antibiotic1 Resistance rate (%)
Ampicillin 73
Trimethoprim-sulfamethoxazole 56
Chloramphenicol 43
Ciprofloxacine 22
Gentamicin 18
Cefotaxime 12
1 Studyin Semarang and Surabaya, 2001. Samples from rectal and nasal swabs,
with a total of 5,535 E.coli strains from 3,284 individuals.

Table 2 shows various antibiotics that E. coli has already become resistant to in Indonesia.
A patient with common bacterial infections such as bacteremia, urinary tract
infection (UTI), cholecystitis, diarrhea, neonatal meningitis, and other
clinical infections (incl. pneumonia) has 73% chance of not showing any improvement if
treated with ampicillin intravenously (IV) or intramuscularly (IM or per injectable) or per
oral (Amoxicillin capsule).

Table 3 Antimicrobial resistance (AMR) rate against Staphylococcus aureus


Staphylococcus Aureus1 Resistance rate (%)
Methicillin (MRSA) 28.0
Tetracycline 24.9
Chloramphenicol 9.4
Trimethoprim-sulfamethoxazole 6.6
Erythromycin 3.3
Gentamicin 1.1
Oxacillin 0.6
1 Study in Semarang and Surabaya, Indonesia 2001. Samples from rectal and nasal swabs collected
strains S aureus was 362 out of 3,995 individuals

Staphylococcus aureus strains showed a 28% resistance rate to Methicillin, and this is a
problem that lead to unnecessary deaths in hospital (due to nosocomial infections).
Antibiotic-resistant strains limit the therapeutic options, put lives at risk, and place a
burden on the health care system. In the hospital setting, AMR of S.aureus isolates varied
from as low as 6.6% for Trimethoprim-sulfamethoxazole to as high as 28% for
Methicillin(43). Trimethoprim-sulfamethoxazole (TMP-SMX) are the frequently
prescribed drugs for urinary tract infections (UTI). But 56% E. Coli are now resistant to

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TMP-SMX, this drug is no longer a first-line empirical therapy. The resistance rate to
Chloramphenicol is 43%. Ciprofloxacin, the second option for treating UTI, showed a
resistance rate of 22%. The overuse of antibiotics and resistance in bacteria also induces
resistance to other classes of antibiotics as well, such as 18% resistance rates against
Gentamicin and 12% against Cefotaxime. These antimicrobial resistance tests need to be
followed up in 2019-2020, to assess possibility of a much higher AMR result.

3.2 Zoonotic diseases in Indonesia


Zoonotic diseases are diseases that spread between animals and humans. These diseases
can be caused by a range of pathogens such as viruses, bacterial, parasites, and fungi. Of
the 1,415 pathogens known to infect humans, 61% are zoonotic. Aside from the awareness
of potential importation of diseases such as Ebola and MERS-CoV, the previous national
priority zoonotic diseases in Indonesia included rabies, anthrax, avian flu, brucellosis,
and leptospirosis, with avian influenza considered endemic in parts of Indonesia and
possibly the highest risk for a pandemic (previously listed in the Presidential Regulation
No.30/2011).

Under Indonesia Law number 24/2007, disasters can be categorized as natural, non-
natural and social. Non-natural disasters are caused by incidents or a series of incidents
such as an epidemic or disease outbreaks. In the past decades, Indonesia has been
significantly impacted by non-natural disasters. Specifically, zoonotic diseases such as
Anthrax, SARS, Avian Influenza, Rabies and Leptospirosis, have caused fatalities and
threatened the lives of animals and humans, with an estimated economic loss of about 20
billion USD in the last decade, with over $200 billion in indirect losses to affected
economies as-a-whole (World Bank, 2010).

Infectious disease disasters are events that involve a biological agent/disease and that
result in mass casualties, such as a bioterrorism attack, a pandemic, or an outbreak.
Infectious disease disasters are different from other types of disasters because they
increase the risk of communicable disease spread during and after the incident.
Subsequently, they involve the need for specialized and multisectoral mitigation,
planning, and response interventions to prevent and control the spread of disease.

The need for multi-sectoral and multi-stakeholder coordination and collaboration to


effectively prevent, detect and respond to zoonotic disease threats is recognized at
regional and global levels. With the dissolution of Presidential Regulation no. 30/2011
regarding Zoonotic Disease Control, and with its replacement by Presidential
Regulation no. 116/2016, it is imperative to develop an effective strategy to maintain and
advance the efforts in preventing, detecting and responding to zoonotic and EIDs.
Currently, zoonotic and EID are not listed as national priorities. The current Presidential

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Regulation has also not yet provided clear guidelines for coordination and collaboration
between the ministries or across coordinating ministries to address these complex health
security threats. As non-natural disaster poses a risk to everyone, preparedness and
response is everybody’s business. Therefore, it is crucial to share the responsibility in
building and improving non-natural disaster preparedness and response capacities in all
relevant sectors, and not solely under human health within the MoH.

Table 4 Incidences and case fatality rates (CFR) of zoonotic diseases in Indonesia, 2009-2017
Diseases(ICD XI) Measure Year
Virus/bacteris 2009 2010 2011 2012 2013 2014 2015 2016 2017
Rabies(1C82) Number of 195 206 184 137 119 81 118 86 90
rabies virus cases
CFR (%) 100 100 100 100 100 100 100 100 100
Bird Flu (XN4TT) Number of 9 12 9 3 3 2 2 - 1
avian influenza cases
virus CFR (%) 77.8 83.3 100 100 100 100 100 - 100
Anthrax(1B97) Number of 17 31 41 22 11 48 3 52 -
bacillus anthracis cases
CFR (%) 11.8 3.2 0 0 9.1 6.3 0 0 -
Leptospirosis(1B91 Number of 335 857 239 640 550 366 833 640
) leptospira spp cases
bacteria CFR (%) 6.8 9.5 12.1 9.3 11.2 17.7 7.4 16.8
Dengue Incidence - 65.7 27.6 37.2 45.8 39.8 50.7 78.8 22.5
Fever(1D21) Rate1
dengue virus
Brucellosis(1B95) Prevalence - - - - - - - 7.02 -
bacteria brucella Rate
1 IR:
Incidence Rate per 100,000 population is a measure of the frequency with which a disease occurs in a
population over a specified time period. Sources: Ministry of Health-Pusdatin. Profil Kesehatan Indonesia 2016
and 2017 (44)(45)

a. Rabies. Rabies is still a priority zoonotic disease because of the impact on socio-
economics and public health. In 2015, the world called for action by setting a goal of zero
human dog-mediated rabies deaths by 2030, worldwide. In 2017, 90 deaths were reported
in Indonesia due to rabies in Indonesia (rabies is 100% lethal in animals and humans
beings) (see Table 4). Currently, out of 34 provinces, only nine provinces are declared as
rabies-free, and rabies is still endemic in 24 other provinces and may actually be
increasing, with a recent spread into West Kalimantan and from there transboundary into
Malaysia. The provinces that are considered rabies-free are: Bangka Belitung, Kep. Riau,
DKI Jakarta, Central Java, DI. Yogyakarta, East Java, West Nusa Tenggara, West Papua,
and Papua (46). Provinces which have suffered new incursions or wider spread of the
virus over the last ten years, still struggle to control the disease in animals due to under-

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funding of local control and eradication efforts, and poorly coordinated and monitored
animal vaccination campaigns.

b. Avian influenza (bird flu), While human cases have continued to decline significantly
since the initial outbreaks in 2003, Indonesia still has the second highest number of H5N1
bird flu cases/deaths (200/168) behind Egypt 359/120) showing a lethal 84% fatality rate
with AI outbreaks in poultry continuing to occur routinely. The MoH-Pusdatin data
showed a decline in the number of fatal human avian influenza (bird flu) cases from 55
cases in 2006 to 2 cases in 2015; and one fatal case in 2017 (see Table 4). However,
according to CDC 24/7: Saving Lives, Protecting People, Indonesia, Vietnam and Egypt have
reported the highest number of cases, out of the cases found in 15 countries since
November 2003 (47). The significant decline in fatalities and human cases of bird flu in
Indonesia was due to extensive interventions to improve H5N1 Highly Pathogenic Avian
Influenza (HPAI) surveillance, disease detection and laboratory diagnosis, prevention
and control; this has now expanded to detection of undiagnosed animal diseases and
emerging infectious diseases (EIDs). The One Health approach requires improved animal
health service delivery and strengthened collaboration between the MOA Directorate
General of Livestock and Animal Health Services (DGLAHS) and the public health and
wildlife health sectors, educational institutions, professional associations and private
sector poultry producers (including smallholder rural farming households)(48).

Evidence-based research. Since 2006, the United States Agency for International
Development has supported Indonesia’s efforts to address zoonotic diseases such as
avian influenza and prevent, detect and respond to emerging disease threats through a
One Health approach. With over $100 million (USD) in support to-date in Indonesia,
USAID has helped Ministries of agriculture, health and others strengthen surveillance
and diagnostic systems as well as build capacity across a wide range of technical and
programmatic areas. The current 2014-2019 Emerging Pandemic Threats Program (EPT2)
aims to support Indonesia’s prevention of new zoonotic disease emergence; the early
detection of new threats when they do emerge; and their timely and effective control.
EPT-2 builds on the lessons and knowledge from its predecessors and brings heightened
focus to those “places and practices” that enable not just “spill-over” of new microbial
threats, but also potentiate its “amplification and spread.” EPT-2 also invests heavily in
One Health policies and capacities needed for prevention and control.

This One Health approach, including “Four Way Linking” (coordination among animal
and human labs plus animal and human surveillance), has been trialed through the
DGLAHS-FAO USAID-funded avian influenza projects and the EPT2, as well as the
Australia Indonesia Partnership for Emerging Infectious Diseases (AIP-EID) Phase 1 and
2. One of the activities was to strengthen the Indonesian government animal health

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information system and public health surveillance systems. The results have proven that
the enhanced national animal health information system (iSIKHNAS) has the potential –
if applied more rigorously to animal health – to improve and strengthen emergency
management and better use of information to support public health surveillance,
veterinary service delivery, policy development and advocacy. Core capabilities of
veterinary services were strengthened in the areas of information systems, veterinary
leadership and quarantine operations. At the sub-national level, training in animal health
and non-technical areas on planning and advocacy was delivered in tandem with support
for local disease control programs (47).

c. Anthrax. Anthrax is an occupational hazard among farmers, cattlemen, slaughterers


and workers who process hair, wool and bone products. Farmers and cattlemen may
become infected by anthrax through several mechanisms affecting cutaneous,
gastrointestinal and respiratory systems. Data from the MoH Pusdatin 2009-2017
reported 225 cases of anthrax, with a peak in human (52 cases) in 2016. The highest
number of human deaths due to anthrax was three in 2014 (see Table 4). The infections
were controlled after deploying intensive surveillance activities in endemic areas even
during religious festivals (Idul Fitri, Idul Adha, Christmas) and other big holidays when
people had increased meat consumption. This was accompanied by livestock services
cattle vaccination programs. The provinces that are considered endemic for anthrax are:
Jakarta, West Java, Central Java, West Nusa Tenggara, East Nusa Tenggara, South
Sulawesi, Central Sulawesi, Southeast Sulawesi, West Sumatera, Jambi, and Yogyakarta.

d. Leptospirosis. Leptospirosis is an acute zoonotic disease caused by leptospira bacteria


that is still a public health problem in Indonesia,mainly in areas prone to flooding. This
disease can be fatal. Between 2009 and 2016, Leptospira bacteria showed a high number
of cases occurrence in 2011 and then declined in 2015, before increasing dramatically in
2016(49) (see Table 4). A reported “extraordinary incidence” (KLB) of Leptospirosis
occurred in Kota Baru, South Kalimantan in 2014. An increase in cases occurred in Central
Java and DKI Jakarta after these cities were flooded. Currently, there is no policy from
the MoH regarding mass treatment delivery, considering that Leptospirosis is relatively
easy to cure with antibiotics, if diagnosed early(50).

e. Brucellosis. The first case of brucellosis in Indonesia, caused by Brucella abortus was
detected in 1915 in cattle in Java. Today, Indonesia’s livestock herds are still not Brucella-
free. Out of 34 provinces, only 8 provinces are considered free of animal brucellosis,
namely Riau, West Sumatra, South Sumatra, Lampung, Bengkulu, Bangka Belitung, Bali,
West Nusa Tenggara, East Nusa Tenggara and all islands of Kalimantan (51). A 1995
study found that the prevalence of Brucellosis among Jakarta cattle slaughterhouse
workers was 13%. A brucella sero prevalence study found a 7.2% prevalence among 57

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dairy farm workers in Garut district in 2016(51). Brucellosis prevention consists of
vaccinating livestock. However, the same study found that merely 10.5% of dairy cows
had been vaccinated. The majority of dairy cows are not vaccinated, and have the
potential to infect other cattle, contaminate their livestock pens and transmit the disease
to humans. Unfortunately, controlling brucellosis in beef cattle herds is very difficult.
Although farmers may receive compensation to cull brucellosis-positive reactors from
their cattle herds, beef farmers in Java have been reluctant to do so and persist in selling
reactor animals in the marketplace. This promotes brucellosis transmission and spread
to unaffected herds and makes control of the disease very difficult(51). However, in
Sumatera a brucellosis compensation scheme gave better results, where all provinces are
now free with the exception of Aceh. Even though the compensation scheme varied
between Sumatran provinces, brucellosis freedom was achieved. For example, North
Sumatera implemented a 5-year compensation scheme, with IDR 1 million paid to the
farmer per positive reactor culled by the provincial livestock service (Dinas Peternakan),
using central government deconcentrated (Dekon) funds. In addition the farmer could
also sell the carcass meat to the slaughterhouse, thus increasing the remuneration he
received for agreeing to cull a positive animal. In other provinces in Sumatera, the
compensation scheme was different, e.g. Dinas Peternakan bought the positive reactor
animal directly from the owner. Recently, the AIP-EID Phase 2 project (2015-2018) has
strengthened emergency management and the use of information to support public
health surveillance(52). But the project reports also a shortage of veterinarians in all
regions, the needs to initiate the Field Epidemiology Training Program for Veterinarians
(FETPV), the needs to conduct training on algorithms, SOPs for specimen collection,
packaging and transport, ways to manage the high turnover of human resources at local
government level; and sources to operate a laboratory information system that is
interconnected with the primary database in iSIKHNAS (52).

3.3 Food safety


Food safety is another shared responsibility requiring the active participation and
collaboration of a number of players along the food chain, from the primary producer to
the consumer. The links between food and health, and food safety risks, have received
much attention in the last decade(53). In 2010, the 63rd World Health Assembly adopted
a resolution to advance food safety, that requires WHO to: (i) provide evidence data on
decreased foodborne health risks along the entire food-chain; (ii) improve international
and national cross-sectoral collaboration in risk communication and advocacy; and (iii)
provide leadership and assist in the strengthening of risk-based, integrated national
systems for food safety(54).

ASEAN leaders made a decision “to create a single market and production base which is
stable, prosperous, highly competitive and economically integrated with effective

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facilitation for trade and investment in which there is free flow of goods, services and
investment”. The ASEAN food safety policy addresses all sectors concerned with food
safety assurance and control, including agriculture, health, industry and trade. ASEAN
also recognizes the role of AMR/AMU on human health and in livestock. ASEAN has
developed guidelines for the prudent use of Antimicrobials in livestock (55).

a. Food safety system in Indonesia


Indonesia has many regulations related to food safety. The first national regulation
regarding food was Act No.7/1996 on Food, followed by a government regulation
No.18/1999 on food labeling to mandate the use of standard labels displaying the content
of the package outside the food packaging. Then a regulation No.28/2004 on food safety,
quality and nutrition was announced; followed by a Permenkes No.1096/2011 on food
hygiene and sanitation; No.1098/2011 on Hygiene and Sanitation for Restaurants; No.
942/2011 on Hygiene and Sanitation for Street Vendor; Law No.18/2012 on Food;
Regulation No. 2/2013 on Foodborne Disease Outbreak; No.43/2013 on Drinking Water
Depot Hygiene and Sanitation and No 492/2013 on Drinking Water Quality (56).

However, frequent foodborne disease events are still rampant, with West Java, Central
Java and East Java provinces having the highest incidences of outbreaks between 2014
and 2016. Food prepared in households was the main cause. The mechanism for
detecting and responding to foodborne disease and food contamination is still not
functioning fully. The coordination at central level, between the MOH, the National Drug
and Food Control Agency (BPOM) and the Ministry of Agriculture (MoA) is still
inadequate. At national and sub-national levels, each of these Ministries has its own
strategic plans to ensure food safety. The Sub-Directorate of Surveillance, Directorate
General of Diseases Prevention and Control, MoH has an early warning alert and
response system (EWARS) for outbreak monitoring and response. Upon receiving
rumors of an outbreak of foodborne disease, the sub-national rapid response teams with
supervision from the central level, will perform the epidemiological investigation and
include epidemiologists, entomologists, medical officers, sanitarians, laboratory officers
and food inspectors from the local Food and Drug Agency and/or animal health agency,
and also provide prevention and control measures. The Sub-Directorate of Food Safety,
Directorate of Environmental Health will identify and confirm etiological agents and the
sources of outbreaks, and then implement corrective action, monitor and evaluate food
hygiene and sanitation according to their approach. In short, the current multi-sectoral
coordination is still inefficient. The formal networking platforms does not facilitate
improvement in communication and information sharing. Environmental, food and
laboratory investigations are not optimally linked, and the risk profiling of food safety
problems requires further attention(57).

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The Coordinating Ministry for Human Development and Culture (Kemenko PMK),
previously named the Coordinating Ministry for Human Welfare (Kemenko Kesra), was
the one that established the Integrated Food Safety System in 2004. Current situation
showed lack of information sharing mechanism across units in the MOH, MOA and
NADFC during outbreaks. The focal points of relevant international organizations
dealing with food safety, such as WHO and the International Food Safety Authorities
Network (INFOSAN); the World Organization for Animal Health (OIE); the Food Control
System (CODEX); the World Trade Organization (WTO) Agreement on Sanitary and
Phytosanitary Measures (SPS), and the OIE Performance of Veterinary Services Pathway
(OIE PVS pathway) should provide guidance needed(57). Risk assessment process, the
scientific evaluation of known or potential adverse health effects resulting from human
exposure to foodborne hazards, needs to be established, from hazard identification to
hazard characterization (qualitative and/or quantitative evaluation of the adverse effects
associated with biological, chemical, and physical agents that may be present in food), to
a dose-response assessment for chemical agents, biological or physical agents, and the
qualitative and/or quantitative evaluation of the degree of intake (58).

b. Food safety cases/incidences in Indonesia


Indonesia’s National Standardization Agency (NSA) issues a national standard license
called Standar Nasional Indonesia (SNI) which is compulsory for each food manufacturer
to comply with its requirements. The agency to monitor food safety is the Food and Drug
Supervisory Agency or Badan Pengawas Obat dan Makanan (BPOM) Indonesia. In general,
the level of acceptance and application/enforcement of SNI standard guidelines are still
low, indicating an impending problem. This explains why 59% of Indonesian food
products are rejected for entry to the United States, Australia and others. About 27% of
these food products were accused to contain salmonellae (59).

The reported food-borne outbreaks between 2014 - 2016 confirmed a total of 7,487 cases
with 20 deaths (see Table 5). More outbreaks were reported in 2015-2016. The common
concerns are strongly related to the use of additives in foods, added substances such as
melamine in powder infant formula, sweetened condensed milk that contains very little
milk, emerging pathogens such as Enterobacter sakazakii, canned sardines contaminated
with tapeworms, and toxic plastic packaging. Percentage of outbreaks associated with
microbiological hazards have been established, but no specific pathogens could be
etiologically linked to most outbreaks. Home produced foods are the cause of food-borne
disease outbreaks (46.9%), followed by catering food (18.9%), with E. coli as the most
common pathogenic bacterial causal agent (74.9%). The contributing factors were
inadequate cooking time and inappropriate storage temperature. Intensive monitoring of
food manufacturing is vital to establish whether food-handling meets the necessary food
safety standards(56).

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Table 5 Profile of Food-borne Diseases Outbreaks, 2014-2016
Year Outbreaks Exposed Ill-health (n=7,487) Dead CFR1 (%) IR2 (%) AR3 (%)
2014 Nd 4,440 1,885 10 0.53 0.8 42.5
2015 66 8,263 2,251 3 0.63 0.95 42.5
2016 98 5,673 3,351 7 0.21 1.41 59.19
1 Case Fatality Rate: the number of deaths divided by total cases during KLB period times 100%
2 Incident Rate: number of cases divided by total population times 100,000
3 Attack Rate: number of cases during the KLB period divided by the number of people who consume

the food times 100%


Source: National Drug and Food Control Agency. Annual Report 2014-2016 (60)(61)(62)

WHO identified a total of 31 dangerous agents (including viruses, bacteria, parasites,


toxins and chemicals) that caused 600 million morbid events and 420,000 deaths. Causes
of diarrhea include norovirus, Salmonella enterica, Campylobacter and E.coli. The main
causes of death from food-borne diseases are Salmonella typhi, Taenia solium, hepatitis A
virus and aflatoxin. According to PERMENKES No.2/2013, food poisoning is defined as
“the pain experienced by a person with symptoms and signs of poisoning such as nausea, vomiting,
sore throat and breathing, stomach cramps, diarrhea, visual impairment, bloating feeling,
paralysis, fever, chills, tasty, tired, swollen lymph nodes, reddened face and itching, that occur
after consuming food that is suspected of containing biological or chemical contaminants.” Cases
of food mortality due to food poisoning continue to increase. The 2014 Individual Food
Consumption Survey (SKMI) found about 200 reports of Outbreaks of Food Poisoning
occur in Indonesia each year. In 2010, there were 429 reported cases of food poisoning, a
much larger number that what have been reported by provinces (estimated of only 63%).
Data from the MoH and BPOM indicate that the cause of food poisoning is difficult to
determine. As many as 53% of the causes of outbreaks in 2009 were unknown and
decreased to 13% in 2013. Sixty per cent of food poisoning outbreaks are thought to be
caused by bacteria, but there is no laboratory confirmation that bacteria are the cause(56).

3.4 Biosafety and biosecurity


According to the Head of the MoH-National Institute of Health Research and
Development (NIHRD) (Ka-Balitbangkes) (July 2018), the NIHRD (Balitbangkes) did sign a
Memorandum of Understanding (MoU) with the MOA (Kementan) as a commitment to
comply to appropriate biosafety and laboratory biosecurity practices. However, there is
no MoH study on biosafety and biosecurity(48). On the contrary, since 2016 the MOA in
collaboration with the FAO ECTAD (Food and Agriculture Organization of the United
Nations – Emergency Centre for Transboundary Animal Diseases) has conducted a series
of effective biosecurity interventions to reduce the risk of avian influenza viruses and to
control AMR in animals and humans. Indonesia has more than 13,000 clinical human,
veterinary and research laboratories including the Biosafety Level (BSL)-3 laboratory
(recommended by the World Health Organization). Since 2010, NIHRD is supposed to

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carry out research including the identification and characterization of the avian influenza
virus, as well as other emerging and re-emerging infectious diseases. The RPJMN 2019-
2024 should include a clear plan of where the country wants to be in the next five years
and in the next 25 years (Long-term RPJPN) in order to mitigate risks both for laboratory
staff and—in terms of biosecurity—for society in general(63).

Indonesia should be cautious that some most deadliest viruses such as Ebola (average
fatality rates of 50%), Marburg, Hantavirus, Lassa, Rabies, Plague, Smallpox, Dengue,
Avian Flu and recently SARS and MERS with fatality rates of 36%, and Nipah virus (1998
in Malaysia), are pathogens that are permanent threats to the health of people in
Indonesia (64). The NIHRD as the research institute under the MoH is responsible to
handle those high-risk pathogens. Cases of humans infected with the avian influenza
(A/H5N1) virus have been intermittently reported mostly in Southeast Asia since 2003,
before the first human case in Indonesia was reported in 2005; and further191 infection
cases (of which 159 cases resulted in deaths), were reported in August 2012. Its CFR was
the highest compared to other countries which reported more than 100 cases of such
infection. Also, there is an on-going concern over the possibility of outbreak and fatalities
within Indonesia and in the world when the virus transforms into a new type of influenza
with strong infectious ability as the virus spreads widely among people (57). In all, the
government needs to be prepared for outbreaks of these diseases. For example, having
plans for rapid access to international vaccines, drugs and other materials in the case of a
pandemic unexpectedly occurs and the relevant medicines are not available in-country.
This was a significant issue during the H1N1 era where affected countries had no system
for allowing untested (locally) vaccines or medicines into their countries.

The JEE results confirmed that requirements on good biosafety, responsible laboratory
biosecurity and biocontainment practice have not been met. Indonesia has obtained a
score of 3 (developed capacity) for the JEE Tool targets # 6.1 and also score of 3 for targets
# 6.2 (see Table 10). The interpretation of Target 6.1 score of 3 means that the
government’s biosafety and biosecurity system has not been in place for human, animal,
and agriculture facilities. Findings also showed that Indonesia has completed the
legislative foundation, has employed all technical and procedural support available from
certified professionals, has all proper containment overseen by the National Authority
for Containment (NAC), has one Emergency Operating Center (EOC) in Jakarta, and has
made a central, certified biosafety level three (BSL3) laboratory available both for the
human and the animal sectors, with local institutional guidelines for biosafety in
place(57). But, the MoH needs to follow them up with:

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a. instructing the National guidelines for biosafety and biosecurity as mandatory;
b. establish a national strategic bio-risk plan;
c. establish the system for active monitoring and maintaining of up-to-date records
and pathogen inventories within facilities that store/process dangerous pathogens
and toxins;
d. implement a comprehensive national biosafety and biosecurity legislation;
e. develop and implement the laboratory licensing;
f. develop and implement pathogen control measures (i.e., physical containment ,
operational handling, and containment failure reporting systems);
g. start the consolidation of dangerous pathogens and toxins in a number of facilities;
h. start to support diagnostics that preclude culturing dangerous pathogens;
i. start to put into place oversight monitoring and enforcement mechanisms.

It was also reported that there was inadequate awareness and commitment among
stakeholders; some even perceived that biosafety and biosecurity 1 are low priority
subjects, because of lack of knowledge on incidents; the sector is affected by high staff
turnover; and active assessment of all laboratories is difficult due to geographical
conditions(57).

The JEE Target 6.2 score of 3 means that Biosafety and Biosecurity training and practices
have not been fully in place for human, animal, and agriculture facilities. Although,
several products have been produced, there are additional assignments to finalize,
enforce and adapt the national guidelines to the national language, recruit more certified
trainers especially in the animal sector, because not all facilities that work with dangerous
pathogens and toxins have adequate number of trained staffs for Biosafety and
Biosecurity(57). Good biosafety, laboratory biosecurity and biocontainment practices are
fundamental to public security. Because, responsible laboratory practices, including
protection, control and accountability for valuable biological materials will help prevent

1
Definitions: The original definition of biosecurity started out as a set of preventive measures designed to reduce the
risk of transmission of infectious diseases in crops and livestock, quarantined pests, invasive alien species, and
living modified organisms (65). Biosafety is the prevention of large-scale loss of biological integrity, focusing both
on ecology and human health. These prevention mechanisms include conducting regular reviews of the biosafety in
laboratory settings, and strict guidelines to follow, to protect from harmful incidents (65).
Biosafety Level 1 is for work involving well-characterized agents not known to consistently cause disease in
immunocompetent adult humans, and present minimal potential hazard to laboratory personnel and the environment.
Biosafety Level 2 is for work involving agents of moderate potential hazard to personnel and the environment. This
includes various microbes that cause mild disease to human or are difficult to contract via aerosol in a lab setting.
Bio-risk Management is the effective management of risks posed by working with infectious agents and toxins in
laboratories; it includes a range of practices and procedures to ensure the biosecurity, biosafety, and biocontainment
of those infectious agents and toxins.
Biosecurity is a series of measures to protect against the entry and spread of pests and diseases.

26 | P a g e
their unauthorized access, loss, theft, misuse or intentional release; and contribute to
preserving scientifically important work for future generations(65).

3.5 Vaccine-Preventable Diseases


In 1974, the WHO Expanded Program on Immunization (EPI) recommended six vaccines
to protect against six diseases: tuberculosis (BCG), diphtheria, tetanus, pertussis (DTP
vaccine), measles and poliomyelitis. Today, there are more than ten vaccine-preventable
diseases: 1) acute viral hepatitis, 2) bacterial meningitis (incl. Haemophilus influenzae type
b (Hib), Neisseria meningitidis, and Streptococcus pneumoniae), to 3) Diphtheria, 4) Measles,
5) Mumps, 6) Neonatal tetanus, 7) Pertussis (whooping cough), 8) Poliomyelitis, 9)
Rubella and congenital rubella syndrome, 10) Yellow fever, and 11) Japanese Encephalitis
(66).

The WHO also recommends standard of surveillance for selected vaccine-preventable


diseases. An effective surveillance system includes the functions of: a) detection and
notification of health events; b) collection and consolidation of pertinent data; c)
investigation and confirmation (epidemiological, clinical and/or laboratory) of cases or
outbreaks; d) routine analysis and creation of reports; e) feedback of information to
persons providing data; and f) feed-forward (i.e. the forwarding of data to more central
levels). While the needs for disease surveillance are increasing with the threats of EIDs,
we do not know whether the current surveillance on vaccine-preventable diseases have
been evaluated in regard to standard ongoing collection, analysis and dissemination of
health data. And, whether data collected only at the minimum necessary amount that can
serve as guidance to decision-making on matters of public health. Many Local Health
Offices do not have trained staff to collect, consolidate and use data for their own district
planning. Overall, the current surveillance system seems to be substandard in terms of
its effectiveness, and it is unknown whether collection for specimen meet the standards,
or tools for communication, transportation and specimen kits are available (67).

In Table 6 we see there was a total of 129 outbreaks of measles in 2016, with a total of
1,511 cases, much higher than in 2015 (68 measles outbreaks with a total of 831 cases).
Chikungunya declined from 2,282 cases (2015) down to 1,702 kasus in 2016. Diphtheria
cases increased from 252 cases in 2015 to 415 cases in 2016. Case Fatality Rate (CFR) was
zero; records showed that 37% of 252 cases in 2015 and 51% of 415 cases in 2016 were
Diphtheria among children with no vaccination.

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Table 6 Reported outbreaks of vaccine preventable diseases and CFRs, 2015 and 2016
Diseases (ICD XI Code) Outbreak Year
(virus/bacteria) (frequency and total cases) 2015 2016
Measles (1F03) Outbreak frequency 68 129
(morbillivirus) Number of total cases 831 1,511
CFR (%) 0.12 0.06
Chikungunya (1D40) Outbreak frequency - -
(chikungunya virus) Number of total cases 2,282 1,702
CFR (%) 0 0
Diphtheria (IC17) Outbreak frequency - -
(Corynebacterium diphtheriae) Number of total cases 252 415
CFR (%) 1.98 5.8
Chikungunya: a phase-II vaccine trial used a live, attenuated virus, can develop viral immunity in 98% of
those tested after 28 days (85% still showed immunity after one year).
CFR: Case Fatality Rates, the proportion of deaths within a designated population with the diseases over
the course of the disease.
Source: Ministry of Health – Pusdatin. Profil kesehatan Indonesia, 2015 - 2016 (68)(44)

Table 7 Immunization coverages (%) of basic vaccination, Indonesia, 2008-2017


Vaccine 2007a 2008b 2010a 2013b 2014b 2015b 2016b 2017b
BCG1 86.9 90 77.9 93.1 93.5 92.5 90 89.1
DTaP 2 67.7 86,09 61.9 90.3 90.7 85.7 84.8 83.7
Polio 71 87,2 66.7 90.2 90.8 93.9 90.5 88.8
Measles 81.6 75,4 74.4 78.1 78.6 77.4 72.7 70.6
Hepatitis B - 82.1 61.9 86.5 87.6 81.5 84.3 81.5
Complete Immunization3 41.6 nd 53.9 71.7 74.3 24.6 59.9 44.1
1 BCG = Bacillus Calmette Guerin
2 DTaP = Diphtheria-Tetanus-Pertussis
3 completed all BCG, DTaP 1-3, Polio and Measles

Note: Children with incomplete immunization are without protection against viruses or bacteria
a NIHRD MoH. National Health Survey 2007 dan 2010 (children age 12-23 months) (69)(70)
bBadan Pusat Statistik. Welfare statistics 2008, 2013- 2017 (children under-five years) (71)(72)(73)(74)(75)(76)

Table 8 Vaccination coverages (%) of children age 12-23 months, Indonesia, 2002/3-2017
Vaccine 2002/3 2007 2012 2017
BCG 83 85 89 91
DPT-3 58 67 72 77
Polio-3 66 74 76 83
Measles 72 76 80 87
Hepatitis B - - - -
Complete Immunization 3 52 59 66 70
Source: BPS, BKKBN, NIHRD-MoH. Indonesia Demographic and Health Survey 2017: Key Indicator
Report. Jakarta: BPS - Statistics Indonesia; Feb. 2018. p.25 (77).

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Tables 7 and 8 presented data on national immunization coverages in years 2002-2017
from various surveys and reports on Indonesia (on children under-five years), and
showed lower rates compared to WHO data in Figure 2 from the WHO Regional Office
for South-East Asia (EPI Fact Sheet 2017).

100
90
percentage coverage

80
70
60
50
40
30
20
10
0
1980 1985 1990 1995 2000 2005 2010 2014 2015 2016
BCG 61 65 74 77 81 86 88 82 80 81
DPT3 27 60 69 75 72 81 78 78 79
OPV 13 60 71 72 79 82 80 80 80
MNV1 26 58 63 76 77 78 75 75 76

Figure 2 National immunization coverage, 1980-2016


Source: WHO and UNICEF estimates of national immunization coverage, July 2017 revision in WHO-
SEARO. EPI Fact Sheet Indonesia 2017

By province, DTP, Hib and HepB3 coverages showed that Aceh in North Sumatra, North
Kalimantan and Papua provinces were still underperformance (below 70%). These areas
should be monitored closely on children without access to vaccination and only partially
vaccination due to vaccine hesitancy or vaccine stock outs (see Figure 3).

Figure 3 DTP-Hib-HepB3 coverage by province, 2016

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DTP = Diphtheria-Tetanus-Pertussis Hib = Haemophilus Influenzae type B HepB3 = Hepatitis-B 3rd
Source: SEAR Annual EPI Report, 2016, in WHO-SEARO. EPI Fact Sheet Indonesia 2017

Figure 4 Non-polio AFP rate by province, 2016


AFP = acute flaccid paralysis
Source: WHO-SEARO. EPI Fact Sheet Indonesia 2017

Surveillance relies on reporting of acute flaccid paralysis (AFP) cases and laboratory
confirmation through isolation of poliovirus from stool. But, delay of laboratory
confirmation is the problem in Indonesia, due to delay in sample collection and testing.
The implication is there will always be a delayed detection of Polio outbreak in Indonesia.
Although there were at least 80% adequate stool collection rate for three consecutive
years, free status requires non-polio AFP rate of at least 1 per 100,000 children below 15
years. Certification of polio free status of any country requires non-polio AFP rate of at
least 1 per 100,000 children below 15 years and at least 80% adequate stool collection rate
for three consecutive years. In October 2005, the WHO Advisory Committee on Polio
Eradication (ACPE), recommended an operational target for non-Polio AFP rate of at
least 2/100,000 in all endemic countries (see Figure 4).

Complete immunization coverage was the MoH’s key indicator in the last Mid-term
Development Plan 2015-2019. The Permenkes No.42/2013 defines “children received
complete immunization” if they receive a dose of Hepatitis B (birth dose), a dose of BCG
vaccine; three doses of DPT-HB vaccine (or DPT-HB-Hib); four doses of polio vaccine
(polio 1-4); and one dose of measles vaccine. Table 7 shows immunization coverages
reported by the NIHRD based on the National Health Survey 2007 dan 2010 findings
among children age 12-23 months; and the 2008, 2013 – 2017 Welfare Statistics of the
Badan Pusat Statistik (BPS) for children under-five years. Table 8 presents the most recent
findings from the 2017 Indonesia Demographic and Health Survey (2017 IDHS) of
February 2018. We see a lower DPT-3 coverage in years 2007, 2012 (compared with 2013
in Table 7) and 2017; higher Polio-3 coverages on these same three years, and higher
Measles coverages in 2012 and 2017. Overall, the 2017 IDHS report a substantial increase

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of complete immunization from 52 to 70 percent between 2002/3 and 2017, much higher
than complete immunization coverage in Table 7. The difference may be due to different
definitions. A complete immunization in IDHS 2017 refers to children who received BCG,
DPT1-3, polio 1-3, and measles vaccinations only. Polio immunization in the 2012 IDHS
only reported three vaccinations, whereas in the 2017 IDHS reported for three and four
times vaccination (77).

Since 2011 there was a decline in the non-polio AFP rate, which reached 2.04 in 2015 (see
Table 8). Non-polio AFP rate is the incidence of AFP caused by diseases other than
poliomyelitis. In 2006 the rate was 19 with adequate stool rate of 82%; increased to more
than 22 with 87% adequate stool rate in 2007. But, in 2005 only 33% of polio cases could
be confirmed although the overall adequate stool rate of AFP cases was 82%. Presence of
compatible polio cases is an indication of weakness in the surveillance system. Very high
non-polio AFP rate - may have to be considered harmful to the quality of polio
surveillance and polio eradication. This discrepancy of having more than 80% adequate
stool rate for AFP, with considerably less proportion of polio cases being confirmed
despite very high non-Polio AFP rate has to be urgently addressed (78). The WHO-
SEARO EPI Fact Sheet Indonesia 2016 highlights also that 90% routine vaccine
procurement were financed by the government; and 88% spending on routine
immunization program were financed by the central government. Out of 514 districts,
375 (73%) districts had > 80% coverage for DTP-Hib-HepB-3, and 263 (51%) districts had
> 90% coverage for MCV1 (66). These data need to be compared with EPI coverages
reported in Theme #3 RMNCAH.

4. JEE targets and action packages


The Global Health Security Agenda (GHSA) has similar goals to the International Health
Regulations (or IHR 2005), "to prevent, detect and respond to” acute public health risks that
have the catastrophic potential to cross borders and threaten people worldwide. Goals 1
and 2 have four objectives, and Goal 3 has three objectives.
 Goal #1: to PREVENT avoidable catastrophes, has four objectives: to prevent the
emergence and spread of antimicrobial drug resistant organisms; to promote national
biosafety and biosecurity systems; to prevent spillover of zoonotic diseases into human
populations; and, to ensure that 90% or more of one-year old population have gotten
measles containing vaccine.
 Goal #2: to DETECT threats early, has four objectives: to launch, strengthen and link
global networks for real-time bio-surveillance; strengthen the global norm of rapid,
transparent reporting and sample sharing in the event of public health emergencies of
international concern; to develop and deploy novel diagnostics and strengthen
laboratory systems; and, to train and deploy an effective bio-surveillance workforce.

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 And Goal#3: to RESPOND rapidly and effectively, has three objectives: to develop an
interconnected global network of Emergency Operations Centers and multi-sectoral
response to biological incidents; to have the capacity to link public health and law
enforcement for the purpose of attribution in the event of a suspected or confirmed
biological attack; and, to improve global access to medical and non-medical
countermeasures during health emergencies(79).

JEE tools have been used as a voluntary external assessment of whether Indonesia is
meeting its GHSA targets. Included in the JEE are additional core capacities required
under the IHR (2005). Indonesia has played an active part in the growing collaboration
among relevant partners and stakeholders, and coordination with other country
members of the GHSA Steering Group (who are engaged in responding to dangerous
public health threats, such as Ebola, SARS, yellow fever, Zika, anthrax, and others).
Indonesia ended its chairmanship of the GHSA Steering Group at the end of 2016. Results
from the 2017 JEE evaluation served as a baseline measurement, and allow Indonesia to
identify and address specific gaps within the national health security systems(80). Section
2.3.1 shows that much remain to be done.

4.1 Baseline scores earned in the first JEE


The first JEE evaluation (2017) demonstrated that Indonesia has been moderately
successful, because no score 1 (no capacity) in any of the 19 technical areas, and lots of mid-
level of advancement scores 4 and 3(57). However, the exercise was very central
(administratively speaking) in nature and very MOH-focused. The results may not have
captured or reflected the relevant capacity and/or needs of other geographic areas or
sectors.

Table 9 shows score 4 in eight (8) out of a total of 19 technical areas of the 2005 IHR.
Score 4 means Indonesia has reached the level of ‘demonstrated capacity (green)’ or
‘capacity’ is in place, sustainable for a few more years and can be measured by the
inclusion of attributes or IHR (2005) core capacities in national health sector planning
(NHSP) (57).

Table 10 shows score 3 in 15 out of a total of 19 technical areas of the 2005 IHR. Score 3
means Indonesia has reached the level of ‘developed capacity (yellow)’ or a capacity are in
place, however, there remain issues of sustainability, measured by lack of inclusion in the
operational plan and/or lack of a plan to secure funding (57). In three areas (all related
to surveillance) the score was 2.

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Table 9 JEE results at Score 4 on IHR Capacities
Technical areas Code Indicators (as of 2017) Score
P.7.1 Vaccine coverage (measles) as part of national program 4
Immunization P.7.2 National vaccine access and delivery 4
National laboratory D.1.1 Laboratory testing for detection of priority diseases 4
system D.1.2 Specimen referral and transport system 4
Real-time surveillance D.2.4 Syndromic surveillance systems 4
FETP1 or other applied epidemiology training program in
Workforce development D.4.2 place 4
Public health and security authorities (e.g. law
Linking public health and enforcement, border control, customs) are linked during a
security authorities R.3.1 suspect or confirmed biological event 4
System in place for sending and receiving medical
Medical countermeasures R.4.1 countermeasures during a public health emergency 4
and personnel System in place for sending and receiving health
deployment R.4.2 personnel during a public health emergency 4
R.5.3 Public communication 4
R.5.4 Communication engagement with affected communities 4
Risk communication R.5.5 Dynamic listening and rumor management 4
PoE.1 Routine capacities established at points of entry 4
Points of entry PoE.2 Effective public health response at points of entry 4

Table 10 JEE Results at Score 3 on IHR Capacities


Technical areas Code Indicators (as of 2017) Score
Legislation, laws, regulations, administrative
requirements, policies, or other government instruments
P.1.1 in place are sufficient for implementation of IHR (2005) 3
The State can demonstrate that it has adjusted and
aligned its domestic legislation, policies, and
National legislation, administrative arrangements to enable compliance with
policy and financing P.1.2 IHR (2005) 3
IHR coordination, A functional mechanism is established for the
communication and coordination and integration of relevant sectors in the
advocacy P.2.1 implementation of IHR 3
Health care-associated infection (HCAI) prevention and
P.3.3 control programmes 3
Antimicrobial resistance P.3.4 Antimicrobial stewardship activities 3
Surveillance systems in place for priority zoonotic
P.4.1 diseases/pathogens 3
Zoonotic diseases P.4.2 Veterinary or animal health workforce 3
Mechanisms for multisectoral collaboration are
established to ensure rapid response to food safety
Food safety P.5.1 emergencies and outbreaks of foodborne diseases 3
Whole-of-government biosafety and biosecurity system
P.6.1 is in place for human, animal and agriculture facilities 3
Biosafety and biosecurity P.6.2 Biosafety and biosecurity training and practices 3
Effective modern point-of-care and laboratory-based
National laboratory D.1.3 diagnostics 3
system D.1.4 Laboratory quality system 3
Real-time surveillance D.2.1 Indicator- and event-based surveillance systems 3

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Interoperable, interconnected, electronic real-time
D.2.2 reporting system 3
D.3.1 System for efficient reporting to FAO, OIE and WHO 3
Reporting D.3.2 Reporting network and protocols in country 3
Human resources available to implement IHR core
D.4.1 capacity requirements 3
Workforce development D.4.3 Workforce strategy 3
National multi-hazard public health emergency
preparedness and response plan is developed and
Preparedness R.1.1 implemented 3
R.2.1 Capacity to activate emergency operations 3
R.2.3 Emergency operations programme 3
Emergency response Case management procedures implemented for IHR
operations R.2.4 relevant hazards. 3
R.5.1 Risk communication systems (plans, mechanisms, etc.) 3
Risk communication R.5.2 Internal and partner communication and coordination 3
Enabling environment in place for management of
Chemical events Ce.2 chemical events 3
Mechanisms established and functioning for detecting
Radiation emergencies Re.1 and responding to radiological and nuclear emergencies 3
Enabling environment in place for management of
Re.2 radiation emergencies 3

In relation to surveillance, Table 11 shows that JEE scores=2 for MoH’s surveillance (2=
limited capacity) means still in development stage with mix results (57).

Table 11 JEE Results – scores=2 on seven IHR Capacitites


Technical areas Code Indicators (as of 2017) Score
P.3.1 Antimicrobial resistance detection 2
Surveillance of infections caused by antimicrobial-
Antimicrobial resistance P.3.2 resistant pathogens 2
Mechanisms for responding to infectious and potential
Zoonotic diseases P.4.3 zoonotic diseases are established and functional 2
Real-time surveillance D.2.3 Integration and analysis of surveillance data 2
Priority public health risks and resources are mapped
Preparedness R.1.2 and utilized 2
Emergency response
operations R.2.2 EOC operating procedures and plans 2
Mechanisms established and functioning for detecting
Chemical events Ce.1 and responding to chemical events or emergencies 2

The challenges: Going to score 4 or 5 (from 2) will require sustained efforts to rationalize
the surveillance information collected, improved analysis and utilization of the results.
The GoI has approved a national plan for surveillance of infections caused by priority
AMR pathogens, a national plan for HCAI (healthcare associated infections), and a
national plan for antimicrobial stewardship. But has not yet designated sentinel sites,

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facilities, centers, and chosen trained Infection Prevention and Control (IPC)
professionals.

5. Conclusion remarks
The years 2020-2024 should be the realization of what has been created by the current
President: “expanded access to public services, including health services.” The
implementation of a national health insurance (JKN) as an avenue to universal health
coverage (health for all) by 2019, is one of his development plans, along with
infrastructure development in many areas that receive very little attention from the
preceded central government and expansion of other social services.
Regrettably, decentralization in the early 2001 did not make Provincial and District
Health Offices around the country became more responsive to the needs of their people.
The last 15 years was a real challenge for our health systems. The 2015 Rapid Analytical
Review and Assessment of Health Systems Opportunities and Gaps in Indonesia found
that: (1) the current health system is weak, in both accountability and coordination; and
(2) instead of getting closer with the local community, the current decentralized
government shows a poor systemic linkage between authorities and civil society.
Overall, the MoH does not demonstrate the capacity to improve the eight core-
requirements to implement IHR in the next RPJMN period (see Annex 6 Figure 8 on the
Organizational Structure of Ministry of Health under Permenkes No 64/2015)(15). The
‘flagship’ to detect, prevent and respond should be held by the institution that is more
advanced in using the technology to be applied. In the case of responding to public health
emergencies due to epidemic of zoonotic diseases, the technology to control pathogens
that spread between animals and people is within the Ministry of Agriculture (MoA)
Directorate General of Livestock and Animal’s Health. While control of food safety and
research on anti-microbial resistance is within the National Drug and Food Control
Agency or Badan Pengawas Obat dan Makanan (BPOM) which reports directly to the
President (under Presidential Decree No.103/2001) (16). The HSR concludes that the
current state of EPHFs are declining. The MoH has very limited capacity for inter-sector
coordination and collaboration, both of which are vital to an effective disease surveillance
and public health emergency response. Health promotion and prevention are both weak
and have seldom yielded any satisfying outputs and outcomes.
In conclusion, bearing in mind that animal disease outbreaks can trigger a huge economic
costs impact, we should consider animal’s health as important as human’s health.
However, the MoH’s EPHFs have shown a slow response to detect EIDs or other
infections caused by antimicrobial resistance pathogens, no evidence of real-time
surveillance and data analysis, and vague preparedness. It will be irresponsible to
appoint the MoH to handle public health emergencies due to EIDs in the near future.

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